The Neurocritic

Monday, November 28, 2016

Airline travel during the holidays is one big headache. But for some people, “airplane headache” is a truly painful experience. The headache occurs during take-off and landing, is unique to plane travel, and is not associated with other conditions. The pain is severe, with a jabbing or stabbing quality, and located on one side of the head (usually around the eye sockets or forehead).

A 28-year-old man developed severe headache associated with changes in altitude during ascent and descent while flying in an airplane. Jabbing pain over the forehead and between the eyes began within minutes of ascent. It resolved once a cruising altitude was reached, but then returned at the start of descent.

Six years later, another case report noted how rare it is (Domitrz, 2010):

Headache with normal examinations and imaging, occurring during an airplane flight has been rarely reported. We present a young patient with a new type of headache that appeared during flights: take-off and landing of a plane and was not associated with other conditions. This airplane headache is rather rare in population and the pathophysiology of this type is not clear.

This claim is contradicted by 240 miserable passengers who commented on The Neurocritic's 2010 post, which appeared soon after that paper was published. Granted, the comments have accumulated over six years, but they clearly show that it's not an unusual occurrence.

Now, a new Danish survey reveals that up to 8.3% of the respondents suffer from airplane headaches (Bui et al., 2016). The online survey was publicized through the Facebook pages of Scandinavian airlines and related organizations.1 The survey consisted of 14 questions. The first six asked about demographic information, including nationality, age, gender, migraine and history of high altitude headache (HAH). The other questions asked about symptoms, co-occurring medical conditions, and type of flight.

The survey participants were 254 Scandinavian air travelers. Among those, 89 (35%) said they suffer from headaches attributed to airplane travel. However, only 21 (8.3%) met the International Headache Society's diagnostic criteria for airplane headache (e.g., headache lasts less than 30 min, is not due to sinus congestion, etc.).2

The authors defined two groups: the AH group (n = 21; 12 female, 9 male) and the non-AH group (n = 233). The mean age of the AH group was 39 ± 14 years (range 19–67 yrs).

The majority of AH participants (91%) described their headache as unilateral, fronto-orbital or fronto-parietal. The headache was described mainly as “pressing” (43%), but also pulsating (29%) and stabbing (29%). The intensity of headache was described as severe (57%) or moderate (43%).

When asked to provide a possible cause for their headache, changes in cabin pressure during take-off and landing was reported as the most possible cause of their AH (95%).

The AH group was further divided into two subgroups: A medicated-group (n = 5) and a non-medicated-group (n = 16). One person took paracetamol (acetaminophen) and four used triptan drugs (used to treat migraines and cluster headaches). An earlier paper found that triptans may be effective in preventing airplane headaches (Ipekdal et al., 2011).

One caveat of the present study is that the respondents were self-selected: they visited the Facebook pages of airlines and were (probably) more inclined to complete the survey if they suffer from airplane headaches.

What causes airplane headaches? One idea is that reversible cerebral vasoconstriction syndrome (RCVS) could be involved in some cases of AH (Hiraga et al., 2016). The most prominent hypothesis suggests that barotrauma is involved, with pressure changes affecting the trigeminovascular system (Berilgen & Müngen, 2006). The most comprehensive explanation of sinus barotrauma comes from Mainardi et al. (2012), who discuss “the physical changes in the paranasal sinuses due to the modification of external ambient pressure according to Boyle’s Law.”

But why is it that relatively few people experience this excruciating pain during ascent and/or descent? Mainardi et al. (2012) again:

...the most likely AH physiopathology seems to be related to a variety of multimodal contributing factors: anatomic factors, such as acquired or congenital abnormalities of sinus outlet, environmental factors (cabin pressure, aircraft speed, angle of ascent/descent, maximum altitude), concurrent factors that act by reducing the sinus ventilation, such as a temporary mucosal oedema, possibly worsened, in predisposed individuals...

Headache, often severe, usually unilateral and periocular and without autonomic symptoms, occurring during and caused by aeroplane travel. It remits after landing.

Diagnostic criteria:

A. At least two episodes of headache fulfilling criterion C

B. The patient is travelling by aeroplane

C. Evidence of causation demonstrated by at least two of the following:

1. headache has developed exclusively during aeroplane travel

2. either or both of the following:

a. headache has worsened in temporal relation to ascent after take-off and/or descent prior to landing of the aeroplane

b. headache has spontaneously improved within 30 minutes after the ascent or descent of the aeroplane is completed

3. headache is severe, with at least two of the following three characteristics:

a. unilateral location

b. orbitofrontal location (parietal spread may occur)

c. jabbing or stabbing quality (pulsation may also occur)

D. Not better accounted for by another ICHD-3 diagnosis.

Comments:

10.1.2 Headache attributed to aeroplane travel occurs during landing in more than 85% of patients. Side-shift between different flights occurs in around 10% of cases. Nasal congestion, a stuffy feeling of the face or tearing may occur ipsilaterally, but these have been described in fewer than 5% of cases.

Monday, November 21, 2016

Phrenology was the pseudoscience of identifying a person's character and mental abilities on the basis of skull morphology (“bumps on the head”). The enterprise was based on four assumptions (Gross, 2009):

intellectual abilities and personality traits are differentially developed in each individual

these abilities and traits reflect faculties that are localized in specific organs of the cerebral cortex

the development or prominence of these faculties is a function of the activity and therefore the size of the cortical organ

the size of each cortical organ is reflected in the prominence of the overlying skull (i.e., in cranial bumps).

Gall originally identified 27 such faculties on the basis of rather flimsy and idiosyncratic evidence. His protege Johann Spurzheim upped the ante to 35 (or 37), which is what is seen on most phrenology heads.

A new article by Eling, Finger, & Whitaker (2016) reviews Gall's organology (as he called it)1 and summarizes the “history of discovery” of the 27 faculties in a handy table.2

Eling et al. consulted the 1835 English translation of Gall's original work (Sur les fonctions du cerveau et sur celles de chacune de ses parties) entitled, On the functions of the brain and of each of its parts: with observations on the possibility of determining the instincts, propensities, and talents, or the moral and intellectual dispositions of men and animals, by the configuration of the brain and head. Like its French counterpart, this tome is available from archive.org.

Oh here's a highlight. During a lecture, Gall realized the analogy between the skulls of monkeys and women, thereby christening “love of offspring”.

- click on image for a larger view -

In the rest of the paper Eling et al (2016) focus on musical ability, in particular how a five year old girl known as Bianchi influenced Gall's thinking.

Footnotes

1“Organology; or, An exposition of the instincts, propensities, sentiments, and talents, or the moral qualities, and the fundamental intellectual faculties in man and animals, and the seat of their organs.”

2The original table included a column with volume and page numbers for extended descriptions of each of the faculties. In the interest of space, I omitted this.

About Me

Born in West Virginia in 1980, The Neurocritic embarked upon a roadtrip across America at the age of thirteen with his mother. She abandoned him when they reached San Francisco and The Neurocritic descended into a spiral of drug abuse and prostitution. At fifteen, The Neurocritic's psychiatrist encouraged him to start writing as a form of therapy.